[HSF] Acute dissection - what now?

[Hgrmd at aol.com]

Ani,
  There's a big difference in pursuing a staged procedure after  visually 
inspecting the dissected aorta versus PCI and pericardiocentesis.   I don't think 
current imaging techniques would be superior to direct inspection  in 
deciding if staging the procedure was feasible.
However, you're right, maybe we should reassess our management.   
Unfortunately, I suspect it's a lot like the management of post infarction  VSD's.  In 
the old days, the recommendation was to wait at least 6  weeks for the margins 
of the VSD to mature.  However, it was eventually  realized (I think by Cooley) 
that all this did was allow operation for the few  who could survive the 
gauntlet of expectant management.  I suspect the same  would be operant in 
expectant management of acute Type I's.  Though I'm  aware of no randomized trial to 
back up my words, I still believe that the  maximum number of patients with 
acute Type I's are salvaged with immediate  surgery.
 
Hal



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